With a population of over 1 billion, India has an estimated 5.7 million individuals living with HIV, of whom perhaps only 10-12% are aware of their serostatus (0.9% prevalence national estimate, UNAIDS, 2005). The release of no cost antiretroviral (ARV) medication in April 2004 created a large patient influx at overburdened clinics, highlighting the need to identify strategies to provide "teaching opportunities" to target medication adherence among HIV seropositive patients. The site for the proposed application, the Post-Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh is one of the most prestigious research and educational public teaching hospitals in India, and a regional distribution Center to provide antiretroviral (ARV) therapy. Existing programs serving low SES patient populations in various regions of India have identified suboptimal levels of adherence due to stigma and discrimination (Ekstrand et al., 2006a), patient lack of disclosure, the cost of transportation to clinics or pharmacies (Ekstrand et al., 2006a, Wanchu, 2007) and limited access to care (Nukella, 2007). Providers also cite medication stock outs, limited time with patients (Wanchu, in press), medication sharing and staff burnout as contributors. These physical, individual, social and structural factors act as impediments to HIV medication adherence. The overall aims of the proposed study are to develop an intervention to enhance ARV medication adherence among new ARV users in Chandigarh, India. We intend to develop a manualized cognitive behavioral group adherence intervention and compare it with the standard of care (e.g., provider medication directive). Goals of the study are 1) identify patient, provider, illness and contextual factors that influence medication adherence, 2) identify culture specific factors that influence adherence, 3) develop and implement a culturally tailored intervention to enhance adherence, 4) evaluate the effects of a structured adherence intervention on adherence to ARV medications. Eighty HIV+ new ARV using individuals will be randomly assigned to one of two conditions, 1) Medication Adherence Intervention (MAI) group condition: Led by a trained health practitioner, participants will receive medication information combined with problem solving skills in an experiential/interactive group format, or 2) Practitioner Medical Directive (Standard of Care) individual condition: Led by a medical practitioner, participants will receive medication information in an individual format. The objectives of the research program are to learn how Indian patients adapt to consistent ARV use, what influences adherence over time, and to develop an effective intervention that supports the use of ARVs. This research is designed to respond to the major public health risk of the development of resistant strains of HIV as a consequence of non-adherence. The goals of this research represent an important strategy for preventing the development and transmission of medication resistant HIV in northern India. PUBLIC HEALTH RELEVANCE The objectives of this research project are to learn how Indian patients adapt to consistent ARV use, what influences adherence over time, and to develop an effective intervention that supports the use of ARVs. This research is designed to respond to the major public health risk of the development of resistant strains of HIV as a consequence of non-adherence. The goals of this research, the development, implementation and evaluation of a culturally tailored method of increasing adherence to ARVs, represent an important strategy for preventing the development and transmission of medication resistant HIV in northern India.